Doctors and social workers in the same team

Press, 4 October 1977, Page 45

Doctors and social workers in the same team

Some social workers maintain that it is the family doctor’s job to help with medical problems (whatever they are) and that there should be centres in the community where social workers deal with psychiatric and social problems.

Are social workers aware of the cost of providing a service in the community? Can they say how they will work with the professionals who are already in primary health care — the general practitioner and the practice nurse? Is it desirable or possible to try to separate physical from psyhological or social illness? And who would be responsible for 24-hour care, including crisis care, and care at week-ends and public holidays? The G.P. has, traditionally, blocked up the holes in the health care system and plastered over the cracks, but is it likely that they will be ready to carry on after office hours for the social worker centres?

Eileen Younghusband pointed out in her report on social workers in Britain that “where any service becomes universal it must, of necessity, be staffed by a large rtumber of mediocre people and a few who are outstanding.” This is the experience of G.P.s all over the world, including New Zealand. There is great uneveness in the quality, training and professional competence of social workers, and G.P.s do not refer patients to anyone in whom they do not have confidence.

There is often a naivety displayed where a social worker seems to think she is “godzone gift” to counselling, regardless of the professional or ethical procedures, or whether the acceptance of the case might not be in the best interests of the patient. Only the ‘‘outstanding few” seem to have little difficulty with phenomena such as' resistance, trans-

ference and involvement in confrontation.

At present there is no definition of a social worker. There is iro registration and no basic training. The social worker has no identity. Perhaps the future role of the Social Workers’ Association is to define standards, training and qualifications and achieve registration as well as keep on being interested in salaries and conditions of work.

It is the experience of doctors that social workers in centralised institutions change their positions frequently. It is rare to be able to identify social workers th hospitals or government departments who have been in the same job for more than a few morfths or a year or two at the most Recently, the leader of the Social Workers' Association in Christchurch made a statement saying that this constant changing is because of poor pay scales. Perhaps it is related to poor job satisfaction? Perhaps the social workers need to work with general practioners and practice nurses in the practice team?

The few social workers who do work with G.P.s seem to stay in the job longer. They develop their own practices. The patients and the G.P.s get to know her and trust her and her work is correspondingly effective. She works alongside the doctors in conjoint and family thereapy and units like the Geriatric Rehabilitation and Assessment Unit do their job better because she is the link between them and the G.P.s. Medical education has been, always, amongst the good professional preparations. It is appropriate to our society that doctors are developing as much concern for the emotional and social welfare of their patients as they have had, traditionally, for their patients’ bodies. Much of the future of

paediatrics and geriatrics, for instance, lies in the field of mental and family health. It makes sense that coronary heart disease should be prevented rather than build more cardiac units and this is mainly a psychological and social problem.

The family doctor is better trained than he has ever been before. The training of the G.P n both at under-graduate and post-graduate levels, now includes the skills of psychotherapy, counselling and the modem approach to psychiatric illness. Amongst the best psychotherapy available in Christchurch now is that provided by some G.P.s The G.P.’s job is to deal with common problems (this does not mean trivial problems) and he should be responsible for as much care as possible in the primary health care centres. He needs help to do this. The approach should be persona! and family-orientated and he should be accessible and provide services at. the right time, including 24 hour, crisis, accident and emergency care.

His responsibility includes preventive care and health education of all kinds. His expertise should continue to be genralised and kept up to date so that he knows the range of other services and facilities that are available to the patient The G.P. is the point of entry into the health care system; he should refer those things which need the expertise and technology of the secondary and tertiary units; and provide a means by which centralised agencies can reach the local community.

Those who have worked with practice nurses are finding that people need time to get to know the nurses and to accept them. Then, patients begin to approach the practice nurse directly if they think it appropriate but they know, always, that the

doctor and the nurse work together. The G.P.s and the nurses find that, as skill develops, there is blurring of the boundaries between what the doctor does and what the nurse does, and it is important that there should be clear communication and trust between them.

The practice nurse has a kind of effectiveness that other nurses do not have. Unlike other nurses, she is learning to help patients to help themselves. Her role of educator shows great promise and she is developing other basic skills. She is becoming knowledgeable in the basics of counselling; she now understands the anatomy of grief and bereavement.

Co-ordination is neces-

sary and the training of the primary health care physician now includes an understanding of this role and an appreciation of the usefulness of other health professionals. There must be accountability within the unit and someone must be finally responsible to the patient The absence of these things in the organisation of the team in the British national health service is its most unfortunate feature.

In the United Kingdom the practice team exists in name only and is merely a collection of individuals. The practice nurse is appointed and is responsible to an outside nursing heirarchy. It is the same with the social worker. The G.P. is the only one who really belongs, and the

centre has no rights in the selection and appointment of the personnel. The result is that there is, except in rare instances, fragmentation and competitiveness and no accountability within the team.

Our G.P.s have learned from the experience of their British colleagues, and are wary lest the same thing should happen here. They know also that when more than one health professional has final responsibility to the patient then no-one has responsibility and it is the patient who misses out. Leadership and responsibility to the patient does not mean that the G.P. has dictatorial control. Within the health team, the members can be in-

volved in a management and planning relationship as colleagues.

There has been a naive and arrogant point of view amongst social workers that the G.P.s role is to spend a few minutes with the ( patient and see large numbers of patients so that his colleague, the social worker, may spend an hour with a few patients during office hours. One important survey indicated that British G.P.s spent little more than five mintues in consultation with each patient. The deficiencies of the primary health care system in Britain and economic pressures forced the G.P.s to try to fill the gaps. Patients are not happy with this and G.P.s are not tolerating it any

more. For the doctor, it is frustrating, inadequate work involving much personal stress and an inferior service.

There is now an influx of young doctors into general practice in New Zealand and we can look forward to an ending to the shortage if it is not already ending. One of the benefits of the health team is that the G.P. is able to spend more time with patients, and one of the tasks of the practice team is to help the doctor spend an hour with patient if necessary. This applies to social workers, too.

G.P.s and practice nurses have many means of communication with people with the patient himself, through children and other relatives, with sick care and accident care, in preventive work, with admission to hospital, during antenatal care, childbirth, terminal illness and death, where there is bedwetting, marital disharmony, childhood problems and battered children. This multi-faceted relationship is being studied extensively and GP. s and practice nurses are learning new skills as a result — new ways of diagnosing, treating and preventing ill health. This kind of new expertise is a general practice skill and does not arise from specialist or hospital work.

The services available in some practices throughout New Zealand now include: doctors, practice nurses, practice social worker, emergency and accident care over 24 hours (there may be surgery for urgent consultations at week-ends and public holidays), sickness care, care in chronic illness, psychotherapy and counselling, preventive health care and early detection of disease (infants, children and adults), routine immunisations (children and adults), health education, antenatal and postnatal

care, antenatal classes (physiotherapy and discussion groups for the women and their partners), family planning and contraception (for married and unmarried), immunisation for overseas travellers, the taking of laboratory and pathology specimens, legal . advice, physiotherapy, ana pharmacy. Trainee general practitioners are now being trained in general practice, and students in medicine, nursing, dietetics and occupational therapy attend as part of their training. These services are only possible where there is a team work approach and the practice social worker is one of the key members of the team.

The concept expressed in the 1968 Todd Report on medical education is becoming a reality in New Zealand as in other countries — “Personal primary care should be backed by secondary and tertiary care. In the primary health care centre the total needs of the patient can be anticipated, organised and offered, from the stage of prevention to emergency care, after care, and terminal care.”

For many G.P.S, it has been a painful process to learn to work with the practice team and find out

the best way of devel.l oping expertise yet keep' expenses down. At times the patient has been for- | gotten, so the learning begins all over again and standards are rising. The way to keep primary health care personal, yet deliver the technology, is becoming clearer. Christchurch has as good a general practice as anywhere in the world and people come from other countries to see what is being done here.

Professor Kerr L. White of the Department of Health Care Organisation of Johns Hopkins University, visited many countries in the world in 1976 on behalf of the United States Government. His job was to look at primary health care centres and he visited Christchurch in September 1976. He recommended in his report to the United States Government that the kind of centre found in Christchurch is an example of an inexpensive unit doing the right kind of job. He wrote “I was much impressed ... it seems to be the model - of the sort of enterprise that should be fostered by the Government.” It would make sense for the social worker to seek to join the G.P.-practice rrurse team in the existing centres.